Ombudsman finds failings by council in management of support for vulnerable adult who died whilst receiving care services

The Public Services Ombudsman for Wales has concluded that Wrexham County Borough Council did not adequately support a vulnerable adult with learning disabilities, who later died.

An investigation was launched after the Ombudsman received a complaint from Mrs X about the support provided to her sister, Mrs Y, an adult with learning difficulties and a history of alcohol dependence.

Mrs Y had been moved by the council into supported living accommodation, managed for the council by a contracted provider. She had lived with members of her family all her life, but her sister approached social services with the view of Mrs Y leading a more independent life.

Her sister was unhappy that the provider delayed in telling the council of increasing concerns about Mrs Y’s behaviour, despite her regular refusal of support, about the state of her flat and around her drinking.

When the provider finally contacted the council, they were unable to access support for Ms Y, who died in April 2020.

The Ombudsman upheld the complaint. She found that the provider did not escalate matters to the council quickly enough and that the council did not appropriately manage Ms Y’s care when matters were eventually escalated.

She also found that the council did not explore the opportunities to share with Mrs X information about her sister’s condition.

The public interest report also outlined failings in how the council handled Mrs X’s complaint about her sister’s care, with conclusions of an independent investigator not fully included in the investigation findings, nor shared with Mrs X.

The Public Services Ombudsman for Wales, Michelle Morris, said: “This is a sad case of grave injustice and we extend our sympathy to the family.

"We acknowledge that when Ms Y died, the COVID-19 pandemic had already placed severe pressure on the council’s services. Nevertheless, we decided that, given that Ms Y was a vulnerable adult with a history of known alcohol dependence, concerns about her condition should have been escalated sooner, and the council should have offered support when matters were finally escalated.

"Our report is clear that we cannot know whether earlier interventions by the council would have altered the sad outcome for Ms Y. However, we are also clear that several opportunities to intervene were lost."

Morrris said that one of those opportunities was to ensure that Ms Y had all the chances to receive support from her family. "Sadly, we found that because the council did not seek Ms Y’s consent about sharing information with her family, her sister was unaware of Ms Y’s condition and unable to extend that support."

The Ombudsman was also concerned about how Mrs X’s complaint to the council was considered and managed.

"The failings that we identified in that process call into question the robustness of the investigation and its findings," she said. "Although the council was not directly providing day to day care for Ms Y, as the body with overall responsibility for the delivery of its social care functions, the council was responsible for the failings.

"We welcome that Wrexham County Borough Council has now accepted these findings and conclusions and has agreed to implement the recommendations in full.”

The Ombudsman recommended that Wrexham issue a meaningful apology to Mrs X for the shortcomings identified in the Report and:

• implement all the actions identified during the council’s investigation of the original complaint by Mrs X
• remind those it contracts to undertake independent investigations on its behalf to ensure that any findings or critique of the service provided to a client are reflected in their report and findings and not shared separately with the authority
• remind relevant staff of the importance of regular contract monitoring in relation to the delivery of social care services by third party providers, to ensure appropriate intervention if there are concerns about the provision of service or a change in a client’s needs.

In a joint statement on behalf of Wrexham Council, Chief Executive Ian Bancroft, Chief Officer Customer and Governance Linda Roberts, and Chief Officer Social Services Alwyn Jones said: “This was a sad and difficult set of circumstances, and we apologise unreservedly for the distress this has caused to the family. We’ve also been in touch with the family to apologise personally.

“The council has worked closely with the Ombudsman to support the investigation, and fully accepts the findings of the report. The report recognises that staff were trying to achieve a difficult balance between avoiding overly restricting Ms Y’s independence while supporting her safety and welfare, but the errors identified – including the way concerns were escalated and acted upon too slowly – are deeply regrettable.

“The council has agreed to the recommendations in the report, and is fully committed to making improvements. Immediate actions have already been identified and are being implemented, and we’ll be ensuring all of the recommendations are fully implemented.”

Lottie Winson